A discourse of disconnection--challenges to clinical engagement and collaborative dental commissioning.

AIM: While doctors are moving centre-stage into managerial and leadership commissioning roles, the role of clinicians in NHS dental commissioning has retained a mainly representative model. In this paper we describe the discourse of 'rank and file' dental practitioners and the implications of this for clinical engagement and clinical leadership in dentistry. METHOD: As part of an NIHR study of NHS dental contracting a questionnaire was sent to 925 practitioners. The questionnaire included a free text box inviting further comment. We received 113 lengthy narratives in 333 (43%) of the questionnaires returned and so undertook a discourse analysis of this data--focusing on the use of language, shared meaning and how practitioners portrayed their identity and activities. RESULTS: Three discursive repertoires were identified: professional subordination; a disconnected hierarchy; and a strained collegiality. Underpinning these repertoires was the sense of disjuncture between the macro-level (managerial) and micro-level (practice), and the problematic nature of clinical leadership in a profession where dentists' common identity is fractured by their individual clinical and business practice. CONCLUSIONS: This paper presents an insight into the views of dental practitioners in their own words, and the challenges of engaging dental practitioners in a new commissioning era.